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All APPLICABLE INFO MUST
-�BBE'COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number.
RECEtVED
r,
JAN 0 9 1010
Building Permit Application
Permittiri9 Department
Planning and Development Services St. Lucie county
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
PERMIT TYPE: Uk5 C)
Address: 410151 S L h 1— - -
Property Tax ID #: q'a31 ooc> -yoo - Lot No.
Site Plan Name: L- Block No.
Project Name:
440
%� C19J� QGeI�nP I a MCP '�/�v�_�11m,
Additi al work to be performed under this permit -check all that apply:
Mechanical Gas Tank _Gas Piping _Shutters Windows/Doors
� Electric Uxp�lumbing _ppSprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: R1 051 Srcd'I Sq. Ft. of First Floor:
Cost of Construction: $ Jol non Utilities: —Sewer 'Septic Building Height:
Name Qj'q OrN Name:
Address: S Company:
City: State: -��. Address:
Zip Code:. Fax: City:State:_
Phone No. - - Zip Code: _ Fax:
E-Mail: r.I�bloy�l�1 �IE0ln1 Phone No
Fill in fee simple Title Holder on ext page (if different E-Mail
from the Owner listed above) State or County License
If value of construction is $2500 or more, a RECORDED Notice of Commencement is required. -
If value of HVAC is $7,500 or more, a RECORDED Notice of Commencement is required.
DESIGNER/ENGINEER: _ Not Applicable
Name: (WOLD
Address: 2. W-TioRe Lan
City: StateQ L,
Zip: ZV k.-L, Phonea-
MORTGAGE COMPANY: _ Not Applicable
Address:
City:
Zip:
FEE SIMPLE TITLEHOLDER: _ Nat Applicable I BONDING COMPANY: _Not Applicable
Address: Address:
City: a, City:
Zip: Phone: Zip: Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
1 certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in conflict with any -applicable Home Owners Association rules, bylaws or anq covenants that may restrict or prohibjt such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the,•work
in accordance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review: room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING
TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT. MUST BE RECORDED AND
POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR -NOTICE OF COMMENCEMENT." I' �4
igna e-7A ess a/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA f
Sd-��
STATE OF FLORIDA.
COUNTY OF 1 n�
COUNTY OF
The forgoing instrument was acknowledged before me
The forgoing instrument was acknowledged before me
this A�_ day of 200 by
L2r-) \se \ \mil ci�
this day of 20_ by
Name of person making statement. �v
Name of person making statement.
9.
Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification a
Produced
Produced
(Signature of Notary P
(Signature of Notary Public -State of Florida) , •,,.
LLBL 'LL 3eg0;Op
.
Commission No. s®lldx� uulsol S'Agq.�W ,oa° "0 •,
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Com mission No. (Seal)
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COMPLETED
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